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Unreported Sharps Exposures in Orthopedic Surgery Residents: A Silent Majority.

Sharps-related injuries represent a significant occupational hazard to health care workers. The incidence of needle-stick injuries in hospitals is approximately 384,000 per year, with 23% occurring in surgical settings. (1) While the engineering of anti-needlestick devices and federal legislation have reduced rates of sharps injuries in the nonsurgical workforce, injuries in surgical settings have continued to increase. (2-5) Orthopedic surgery residents in particular are at an increased risk of sharps (e.g., bone fragments, blades, and K-wires) exposure due to the amount of time spent in the operating room where they are in contact with a variety of sharps including suture needles, blades, K-wires, and bone fragments. (5-9) A recent study conducted at an urban academic hospital showed that up to 38% of general surgical procedures involved exposure to HCV, HBV, or HIV, further contributing to the problem. (10)

Because the majority of sharps exposures among surgeons in training are never reported, efforts to determine causes and potential interventions are challenging. (3,11) There are relatively few studies examining unreported sharps-related injuries in orthopedic surgery residents, in particular. While previous investigations have described the relatively high number of incidents that go unreported, few studies have examined other factors that may influence reporting decisions. The purpose of this study was to examine the incidence, attitudes, and reporting of sharps injuries among orthopedic surgery residents at a large academic teaching hospital with a particular focus potential factors that may to contribute to non-reporting.

Methods

Current orthopedic house staff (N = 62) were surveyed with an anonymous cross-sectional questionnaire that was created to evaluate the incidence of intraoperative sharps exposures during residency as well as during medical school training (Fig. 1). Sharps exposure were defined as any percutaneous injury with a sharp instrument or device. All participants were provided this definition.

Surveys were made available in both online and paper formats and were completed only by house staff. Both versions of the survey were identical. Survey anonymity was stressed and no identifying information was recorded. Instructions were given for surveys to be placed in an envelope at the respondent's convenience, which was collected by study staff. Individual responses were digitized and paper records were destroyed. An online version of the survey was also emailed to all house staff. Instructions clearly specified that only one version, either the paper version or the online version, was to be completed. Results from both versions were combined for the final analysis.

In order to assess the accuracy of the survey, occupational health and safety (OHS) department reporting records over the last 5 years were audited and compared to the survey results.

Statistical analysis was performed with the use of Pearson's Chi-squared tests. Statistical significance was defined as p [less than or equal to] 0.05. All calculations were performed using IBM SPSS Statistics software version 20 (IBM, Armonk, New York).

Results

Overall, 76% of surveyed residents (41/54) had at least one sharps exposure during residency. When including exposures that occurred during medical school, the incidence increased to 83% (45/54). The range of total exposures was from 0 to 9 (Fig. 2). Most commonly, these resulted from needles sticks, followed by Kirschner wires, bone fragments, and surgical instruments (Table 1). The highest rate of sharps exposures was observed in PGY-4 residents, with the lowest rate of exposures occurring in PGY-1 residents (Fig. 3).

In addition to the timing of each exposure, residents were also asked if they reported the exposure to the OHS department (Fig. 4). Of the 105 sharps exposures reported to have occurred during residency training, 55% (57/105) were never reported. Unreported sharps exposures were more common than reported sharps exposures for all time points other than those occurring in the 2 weeks prior to the survey, where 2 of 3 exposures were reported. According to survey results, for the year 2013, 18 exposures occurred. This is similar to audited OHS data (Table 2), which shows 15 exposures in 2013. Overall, the number of reported sharps exposures has increased since the first year of OHS data collection in 2005. All residents with at least one exposure were asked to complete additional questions regarding their most recent incident. Seventy-one percent (29/41) of residents reported that the patient was tested for infectious diseases after the exposure. Sixty-eight percent (28/41) reported that another member of the surgical team was aware when the exposure occurred. Residents whose exposures were noticed by others on the operating team were more likely to report the incident to the OHS department (57% vs. 23%, p = 0.043). Of the 13 residents with unnoticed sharps exposures, only two alerted the surgical team at the time of exposure. After exposure, 39% (16/41) of residents left the operating room before the procedure was finished. Most of the residents who reported the incident did so within 2 hours of the incident (Fig. 5).

Overall, of residents who reported the incident, 52% (10/19) took prophylactic medication. Of these, only 50% (5/10) finished the entire course. For residents who did not report the incident, reasons for doing so were ascertained (Fig. 6). All residents reported awareness of the institutional protocol for blood-borne pathogen exposure.

Discussion

Orthopedic surgeons are one of the highest risk health care worker populations with regards to sharps injuries, and surgical residents have been found to be at an even greater risk man more experienced attending surgeons. (4,8,12-17) This risk is represented in the present study, where 83% of orthopedic surgery residents reported experiencing a sharps exposure at some point during their medical education. The surgical nature of the specialty does not allow for a reduction in the use of sharp instruments, however, a greater understanding of the causes and attitudes surrounding sharps injuries in orthopedic surgery residents can help us reduce the frequency. (5)
Figure 4 Time to reporting for most recent reported exposure.

         TIME (HOURS)

0 to 2   10
2 to 6    2
6 to 24   0
>24       2

Note: Table made from bar graph.

Figure 5 Reasons for not reporting most recent exposure. Free text
responses included: did not penetrate glove; scratched; after hours,
employee health closed; needed to finish case; literature review from
ED on previous visit; and closed needle, low risk.

Embarrassed                3%
Perceived Low Risk        53%
Too Much Hassle           25%
Other                     19%

Note: Table made from pie chart.


Despite the many different types of sharp objects encountered by orthopedic residents, we found that the vast majority of sharps related injuries were due to needle-sticks while suturing at the end of a case. During this period, there is less likely to be attending surgeon supervision, and members of the surgical team are more likely to feel hurried, which further contributes to needle related injuries. (3,11) Alternatively, the relatively few number of injuries seen from surgical instruments and bone fragments may be due to increased attending surgeon supervision in parts of the case where this risk is highest and the recent implementation of "hands-free" instrument passing techniques at our institution. While needle-sticks remain a major issue, the lack of injuries related to other sharps is encouraging and suggests that orthopedic surgery residents may not be at an increased risk sharps exposure relative to other surgical residents when certain preventative measures are implemented. Because of this, further efforts to reduce sharps injuries in orthopedic residents at our institution will be focused on reducing the risk of needle-sticks, in particular.

Our study found a high rate of unreported sharps exposures, which is consistent with other reports in the literature. (1819) Among the reasons for not reporting sharps exposures, the perception of low risk from the exposure is the most common. This may be due to the increasing amount of literature suggesting a relatively low risk of HBV, HCV, and HIV transmission among health care workers after exposure to contaminated needles. (2023) Regardless, increasing the reporting and follow-up of sharps related injuries is important to help reduce the risk of transmission, provide counseling, and to track occupational health trends. Additionally, reporting exposures is important to ensure Workers Compensation coverage should future claims become necessary. (24) Though not explicitly surveyed, the high percentage of residents reporting that patients were tested for infectious diseases after their most recent exposure suggests that, despite the reported perception of low risk, residents likely feel a significant amount of anxiety after these incidents, as has been reported in the literature. (19,25,26) Proper counseling and follow-up have been shown to help alleviate these feelings. (25,27)

Of particular interest, we found that exposures were less likely to be formally reported if they were not witnessed by another member of the surgical team. While one other study has reported this finding for surgical residents overall, (11) this is the first study to our knowledge that demonstrates this phenomemon among orthopedic surgery residents, specifically. For those with witnessed sharps exposures, there is likely peer pressure from the attending surgeon or other members of the surgical team to assess the possible injury and report to the OHS department if an exposure has occurred. Since the majority of injuries occur while suturing at the end of the case, it is probable that most unnoticed incidents are initially ignored by residents until the case concludes. If an injury has occurred, it may be easier to ignore or deny without external pressure from other members of the surgical team. It is likely that increased reporting rates for sharps injuries can be achieved by encouraging the surgical team to remain vigilant for potential sharps injuries among their colleagues. Reminders could be incorporated into the presurgical "surgical timeouts" and postoperative "debriefings" already in use at many academic medical centers. (28) Additionally, since 57% of those with witnessed incidents still fail to report it, educational programs should emphasize the importance of encouraging members of the surgical team to report incidents should they witness one, perhaps even anonymously through existing needlestick hotlines.

Lastly, our findings also suggest that inexperience plays a role in the number of observed sharps injuries. Our results suggest an increasing rate through early residency with a peak during the postgraduate year 4. While this generally correlates with the amount of operative time, the risk appears to decrease for those in the postgraduate year 5. This may be due to a combination of increasing experience and a lower amount of "needle time" as senior residents delegate suturing to more junior residents.

The similarity between audited OHS data and our survey results on reported sharps exposures in the year 2013 attests to the accuracy of survey. The small difference that is present is likely due to a 1-month difference in assessment windows (survey given in late January, 2014), the lack of data from six residents who declined to complete the survey, and the lack of records from one of the four training sites, which maintains a separate OHS department. The increasing trend of reported sharps exposures to the OHS department at our institution is correlated with, and likely due to, the implementation of a "needlestick hotline" and educational programs in2009 that emphasize the importance of incidents

A limitation of our study includes its sample size, which evaluated house staff from a single program. However, the program used for this study is among the largest in the country and training actively occurs at four separate hospitals. Therefore, it is likely that trends observed in our sample can be generalized to smaller residency programs in a variety of settings. A second limitation includes possible recall error in reporting the frequency of sharps exposures in the past, such as when upper level residents respond to the "number of sharps exposures as a medical student." While this is a possibility, anxiety and emotions provoked by sharps exposures likely limit the effects of this bias. Additionally there may have been sharps exposures not reported in the operating room and to the team, which is why we conducted the initial survey.

Conclusion

The vast majority of orthopedic surgery residents experience a sharps-related injury at some point during their medical education, most commonly with needles while suturing at the end of an operative procedure. The majority of these incidents are never reported. Injuries that are witnessed are much more likely to be reported than unwitnessed injuries, suggesting that peer-pressure acts to improve reporting rates. Surgeon safety as well as resident well-being are of utmost importance. Residents should feel safe, empowered to report incidents, and follow up on any issues to ensure their well-being. While the implementation of a "needle-stick hotline" and increased education has led to improvements in reporting rates at our institution, further improvements aimed at reducing unwitnessed incidents include an emphasis on surgical team vigilance and the incorporation of sharps-specific surgical debriefing statements.

Disclosure Statement

None of the authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.

References

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Arthur Manoli, III, MD, Lorraine Hutzler, MPA, Deirdre Regan, BA, Eric J. Strauss, MD, and Kenneth A. Egol, MD

Arthur Manoli, III, MD, Lorraine Hutzler, MPA, Deirdre Regan, BA, Eric J. Strauss, MD, and Kenneth A. Egol, MD, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York, USA.

Kenneth A. Egol, MD, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, 301 East 17th Street, New York, New York 10003, USA; kenneth.egol@nyumc.org.

Caption: Figure 1 Distribution of total sharp exposures among orthopedic surgery residents.

Caption: Figure 2 Mean number of exposures by postgraduate year.

Caption: Figure 3 Total number of sharps exposures over time: reported versus unreported.

Caption: Figure 6 Survey form used to assess sharps exposure by orthopedic residents.
Table 1 Sharps Exposures by type

Source           Exposures

Needle           88
Kirschner Wires   5
Bone Fragment     5
Blade             4
Rake              2
Electrocautery    1
Drill Bit         1
Spear             1
Kocher            1
Screw             0

Table 2 OHS Data--Number of Reported Exposures by Year for Orthopaedic
House Staff

Year  Exposures

2013  15
2012  12
2011   4
2010   5
2009   6


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Author:Manoli, Arthur, III; Hutzler, Lorraine; Regan, Deirdre; Strauss, Eric J.; Egol, Kenneth A.
Publication:Bulletin of the NYU Hospital for Joint Diseases
Article Type:Report
Date:Apr 1, 2018
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